LarryQC_SD said:

A step that is uncomfortable at week two is frequently comfortable at week six with no change in dose, because the gastric-emptying component…

I disagree that the ladder is purely tolerability. The maintenance and regain data cluster at the top doses, so a ladder abandoned halfway leaves you outside the evidence base for the part that matters most — keeping it off.

ChrisMacros said:

I titrated faster than the label because I felt fine, hit a wall at the third step, and had to come back down — which I now think was the predictable…

Dose escalation anxiety for titration: I was terrified to move from 0.5mg to 1.0mg based on horror stories in this forum. But my actual experience? Slightly more appetite suppression, zero additional side effects.

Remember that the people posting about terrible side effects are a biased sample. Most people titrate up without drama — they just don't post about it because it's uneventful.

Dr.CardioMD said:

I disagree that the ladder is purely tolerability.

Coming at Dr.CardioMD’s question from a different direction. The mechanism and the magnitude are separate questions. Agreeing that something happens says nothing about whether it happens enough to act on.

One thing that is still open after Dr.NateNeph’s answer:

Why the interval is four weeks rather than two, and whether a slower ladder gets to the same place?

Closing the loop on my own question.

Update — I came back down one step, held for a month, then went up again and it was uneventful the second time. Same ladder, slower.